There are few reports describing dislocation of the metacarpophalangeal joint of the thumb in children. This study describes the clinical features and outcome of 37 such dislocations and correlates the radiological pattern with the type of dislocation. The mean age at injury was 7.3 years (3 to 13). A total of 33 children underwent closed reduction (11 under general anaesthesia). Four needed open reduction in two of which there was soft-tissue interposition. All cases obtained a good result. There was no infection, recurrent dislocation or significant stiffness. So-called ‘simple complete’ dislocations that present with the classic radiological finding of the joint at 90° dorsal angulation may be ‘complex complete’ injuries and require open reduction

Paediatric distal radial and forearm fractures account for 37.4% of all fractures in children. We present our 2.5-year results of a novel safe approach to the treatment of simple distal radial and diaphyseal fractures using intranasal diamorphine and entonox in a designated fracture reduction room in the emergency department. All simple fractures of the distal radius and forearm admitted to our ED between March 2012 and August 2014 that could be reduced using simple manipulation techniques were included in this study. These included angulated diaphyseal fractures of the forearm, angulated metaphyseal fractures of the distal radius and Salter Harris types I and II without significant shortening. All children included were given intranasal diamorphine as well as entonox. The orthopaedic registrar on call performed all reductions. 100 children had their distal radius or forearm fracture reduced in the emergency department using entonox and diamorphine analgesia and had a same day discharge. Average age was 10 years (range 2.20–16.37 years). No complications were reported regarding the use of the analgesia and all children and parents were pleased with their treatment not requiring a hospital admission. The mean initial dorsal angulation of all fracture types was 28.05° degrees (23.91–32.23 95% CI) which was reduced to 7.03° (5.11–8.95 95% CI) post manipulation. There were 9 cases lost to follow up. Two cases lost the initial reduction of the fracture on subsequent clinic follow up and underwent internal fixation in theatre. The use of entonox and intranasal diamorphine is a safe, effective treatment of providing adequate analgesia for children with distal radial and forearm fractures to allow manipulation of displaced dorsally angulated fractures in the emergency department. By facilitating a same day discharge, over £45,000 was saved using this safe method of treatment

A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation.

The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED.

By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method.

Take home message: Simple easily reducible fractures of the distal radius and forearm in children can be successfully and safely treated in the ED using this approach, thus avoiding theatre admission and costly hospital stay.

Cite this article: Bone Joint J 2016;97-B:131–6.

In five children, six forearms with a fixed pronation deformity secondary to congenital radioulnar synostosis were treated by a derotation osteotomy of the distal radius and the midshaft of the ulna.

There were three boys and two girls with a mean age of 4.9 years (3.5 to 8.25) who were followed up for a mean of 29 months (18 to 43). The position of the forearm was improved from a mean pronation deformity of 68° (40° to 80°) to a pre-planned position of 10° of supination in all cases. Bony union was achieved by 6.3 weeks with no loss of correction. There was one major complication involving a distal radial osteotomy which required exploration for a possible compartment syndrome.

Redisplacement is the most common complication of immobilisation in a cast for the treatment of diaphyseal fractures of the forearm in children. We have previously shown that the three-point index (TPI) can accurately predict redisplacement of fractures of the distal radius. In this prospective study we applied this index to assessment of diaphyseal fractures of the forearm in children and compared it with other cast-related indices that might predict redisplacement. A total of 76 children were included. Their ages, initial displacement, quality of reduction, site and level of the fractures and quality of the casting according to the TPI, Canterbury index and padding index were analysed. Logistic regression analysis was used to investigate risk factors for redisplacement. A total of 18 fractures (24%) redisplaced in the cast. A TPI value of > 0.8 was the only significant risk factor for redisplacement (odds ratio 238.5 (95% confidence interval 7.063 to 8054.86); p < 0.001).

The TPI was far superior to other radiological indices, with a sensitivity of 84% and a specificity of 97% in successfully predicting redisplacement. We recommend it for routine use in the management of these fractures in children.

Cite this article: Bone Joint J 2013;95-B:563–7.